Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: The interest in and use of mechanically circulatory support, including extracorporeal membrane oxygenation, continues to grow rapidly in critical care medicine.
Speaker: Today, we will focus our discussion on ECPR, Extracorporeal Cardiopulmonary Resuscitation.
Speaker: It may still be considered a niche therapy, but its relevance and availability are increasing.
Speaker: Our guest is Dr. Adam Green, a practicing intensivist at Cooper University Healthcare and an associate professor of medicine at Cooper Medical School of Rowan University.
Speaker: Dr. Green is a director of research for the Division of Critical Care and has authored over 50 peer-reviewed publications.
Speaker: He has been part of the ECMO team at Cooper since its inception.
Speaker: Dr. Green is a recognized clinical educator and has received multiple teaching awards.
Speaker: Adam, welcome to Critical Matters.
Speaker: Thank you, Dr. Zanadi.
Speaker: Thank you for having me.
Speaker: I was excited and honored for the invite.
Speaker: Well, first rule of critical matters, you've got to call me Sergio, not Dr. Zanotti.
Speaker: Oh, I know, I know.
Speaker: It's tough, it's tough.
Speaker: Yeah.
Speaker: You know, I often joke that you left Cooper right before I came, and I think it's because you knew I was coming, and you said, I need to get out of here.
Speaker: Well, what I hear is that you only accepted because I had left, but that's another story.
Speaker: Maybe, maybe, maybe.
Speaker: So as a starting point, I would like to ask you, why do you think this topic of eCPR should be of interest for intensivists?
Speaker: Yeah, I think it's tough.
Speaker: I think, um,
Speaker: When I think about ECMO, and trust me, when I think about my fellowship, we had ECMO.
Speaker: It was mostly decided by CT surgery, and we managed the patients, but for the most part, it was away from us.
Speaker: And I think about how many cases were done then versus now, and there truly has just been an explosion of ECMO in general.
Speaker: And I was looking at ELSO, you know, they publish quarterly or twice a year stats of just how many runs are done, how many centers.
Speaker: And certainly there was a spike during COVID, but it really predated COVID and continues.
Speaker: And I think we're at almost 600 centers and over 21,000 ECMO runs in adults a year.
Speaker: So what that tells me is that even if you're not at an ECMO center,
Speaker: Like it's coming, it's expanding, it's becoming more and more, you said niche, and I think maybe 10 years from now we'll look at it differently.
Speaker: So at least for VB, you should know when to transfer or refer your patients.
Speaker: Probably for VA, well, obviously you're not going to transfer someone for eCPR.
Speaker: I think the more you know about it, the better it is.
Speaker: Perfect.
Speaker: And as we start with some general concepts, could you tell us a little bit more detail?
Speaker: What is eCPR?
Speaker: Yeah, I mean, I think you stole the words exactly, which is this extracorporeal cardiopulmonary resuscitation.
Speaker: So it's exactly what it sounds like.
Speaker: It's using ECMO to support circulation and oxygenation during refractory cardiac arrest.
Speaker: So it's cannulating someone for ECMO while they're undergoing CPR.
Speaker: Technically for ELSO, it's or within 20 minutes of ROSC, but it's that idea of using ECMO to promote ROSC.
Speaker: So it really is the application of ECMO within the cardiac arrest situation.
Speaker: And you did mention something that is very important.
Speaker: You mentioned the refractory cardiac arrest.
Speaker: So this is not something that we just apply to anybody who has VT or cardiac arrest, right?
Speaker: It's for certain cases, correct?
Speaker: Correct.
Speaker: Yeah, and I'm sure we'll jump into some of the inclusion and exclusion criteria, but I think, and this is going to be, th is is probably a theme throughout the next hour of the conversation, which is you always prefer...
Speaker: ROSC through normal ACLS.
Speaker: I never want to put someone on eCPR.
Speaker: I would rather them develop ROSC without the use of eCPR.
Speaker: And that a lot of that has to do with just the complications associated with it and the altering of physiology when you add kind of counter current flow.
Speaker: So I always want ROSC, but I also don't want to wait too long.
Speaker: So it's understanding that exact moment of when to cannulate.
Speaker: So
Speaker: The earlier the better, but not too early if you can get ROSC.
Speaker: I don't know if that makes sense.
Speaker: Yeah, absolutely.
Speaker: But that I certainly would highlight.
Speaker: Yeah.
Speaker: And is there a distinction in your mind in terms of eCPR and out-of-hospital cardiac arrest versus intra-hospital cardiac arrest?
Speaker: Obviously, the literature is evolving, but even in your practice, do you make a distinction?
Speaker: Yeah, so we have different criteria.
Speaker: So first off, they both are adults.
Speaker: They both need to have witness arrest with immediate CPR.
Speaker: So whether that's in the hospital or it's bystander if it's out of hospital.
Speaker: And we tend to be a little more strict with out of hospital.
Speaker: So I really want it to be a V-fib or VT arrest.
Speaker: We will sometimes cannulate PEA if there's clear, purposeful movement.
Speaker: So when you're doing compressions, they're reaching for the tube.
Speaker: But I need to be pretty convinced.
Speaker: Now, that's different for in-hospital cardiac arrest, where it could be a PEA.
Speaker: I think it's immediate reversible.
Speaker: I understand why they're arresting.
Speaker: And I guess the cutoffs, I would say, is three defibs.
Speaker: That's kind of the time where we pull the trigger.
Speaker: Or 15 minutes of ACLS.
Speaker: That's the time when we'll decide to start cannulation.
Speaker: So that's how you're defining refractory cardiac arrest, right?
Speaker: Either they got three episodes of defibrillated three times without success or temporary success, or you've been at it for 15 minutes.
Speaker: So really, it's not something that happens immediately, but that happens after CPR has been initiated.
Speaker: That's right.
Speaker: That's right.
Speaker: And if you just think about the timing of it, like it's, I kind of wish, I wish you would be, you know, I could take you and show you a video and like put you in the scene, but you know, patients coming in, ideally it's for out of hospital, it's less than 30 minutes between when they arrest and when they actually hit the ER and it takes time to mobilize your team.
Speaker: And so I think we'll talk about studies and it's really, you want that low flow or the CPR time to be as low as possible.
Speaker: And usually neurological, uh,
Speaker: recovery is in the realm of 40 minutes or so.
Speaker: So if it takes them less than 30 minutes to get there, you have 15 or 20 minutes to pull the trigger and get them on.
Speaker: And the procedure itself takes time, right?
Speaker: So it's, once again, that balance of looking at the chart, making sure there's no contraindications, deciding to do it, get your whole team ready, and then actually cannulating.
Speaker: And so it's split second.
Speaker: You have to kind of, you have to be able to make the decision quickly.
Speaker: And I think, Adam, that when we talk about cardiac arrest outside of the context of ECPR, we usually talk about
Speaker: shockable rhythms, non-shockable rhythms.
Speaker: We might talk about downtime.
Speaker: We might talk about bystander CPR.
Speaker: We might talk about concepts like ROSC as part of what we're describing clinically.
Speaker: But it seems that three words or three terms that are very important in describing and understanding the cardiac arrest itself when it comes to eCPR are refractory,
Speaker: no flow time, and low flow time, correct?
Speaker: Right.
Speaker: Could you expand on those?
Speaker: Yeah, so low flow would be no CPR.
Speaker: So for eCPR, that needs to be zero.
Speaker: If it's a young person who's found down and a bystander doesn't know when, they don't feel pulse, and they start CPR, that's a no-go.
Speaker: So there's no flow time there.
Speaker: When we use the term low flow, that would either be manual compressions by a
Speaker: A healthcare provider or a bystander or a Lucas device would be low flow.
Speaker: And downtime is generally used, I guess, from all of that combined.
Speaker: It's a time between when they have the arrest and then when you actually get ROSC or ECMO flow, if it's eCPR.
Speaker: Excellent.
Speaker: Now, this is obviously, as you mentioned, also a growing area of interest, a growing application of ECMO in the cardiac arrest environment.
Speaker: What does the literature say?
Speaker: I know there are some studies out there.
Speaker: Could you just give us maybe at a very high level some of your insights or comments in terms of what's been studied and what's out there?
Speaker: Yeah, how much time you want to talk about it.
Speaker: So I think there's a handful, and you'll notice all of the publication dates are 2020 and onward.
Speaker: So it's all recent stuff, right?
Speaker: There's probably three main RCTs.
Speaker: The largest one is through the Prague Group, which had...
Speaker: Out of hospital cardiac arrest, it was field ACLS, essentially stay and play versus pick them up and go versus eCPR at the hospitalization.
Speaker: And for the most part, and I would say all three studies, and I'm happy to go into detail if you'd like.
Speaker: all show that eCPR outperforms ACLS in this population in terms of survival.
Speaker: And really the outcome we care about is neurological recovery.
Speaker: So CPC of one or two.
Speaker: And when we are looking at numbers, it varies.
Speaker: Some of the studies are pretty small, but I would say maybe 30%, 20 to 30% of eCPR.
Speaker: And then ACLS is less than that.
Speaker: So we're
Speaker: not talking about high survivable, right?
Speaker: So those are like the RCTs.
Speaker: And then I think there's two major registry studies.
Speaker: So one is through this Japanese registry that had over 1600 patients, and they showed that survival with CPC of one or two to be 14%.
Speaker: So really low, right?
Speaker: So it sounds it's, you know, fun and sexy technology, but still, we're not talking about great outcomes in the majority of patients.
Speaker: And in that study, I think it's worth highlighting that the time to eCPR was under an hour, but in the 50, 55-minute range.
Speaker: And complications happen in almost a third of the patients.
Speaker: And I think ELSO reports something similar.
Speaker: I think maybe it's better 20 or 30 percent say that the patient survived that had eCPR done.
Speaker: And in terms of guidelines, what are the current guidelines recommending for eCPR?
Speaker: Yeah, I think that's hard.
Speaker: I'm not sure.
Speaker: You know, ELSO has some guidelines.
Speaker: There's some other associated guidelines.
Speaker: I think generally it's going to be a healthy person that's less than 70 years old that has no major comorbidities.
Speaker: So we're taking people on dialysis, people with NSAID heart disease, people with oxygen requirements or malignancy generally are not candidates.
Speaker: And they're saying the same thing.
Speaker: You want time from ER to, or from arrest to ER to less than 30 minutes.
Speaker: And you want time to cannulation somewhere around 45 minutes if you can.
Speaker: The other thing that's at play that we look at is end title.
Speaker: So if you have a consistent end title less than 10 during, during arrest, that is a reason to not cannulate.
Speaker: That's a marker of, of poor, of poor neurological outcomes.
Speaker: So really it's about patient selection.
Speaker: But I thought it was important to start with a brief discussion at a high level, and we'll add these references to the show notes, because there is some studies.
Speaker: There is data that's emerging and that we should be paying attention, right?
Speaker: Even if you're not doing eCPR today in your institution, you might soon.
Speaker: So
Speaker: When we talk about practical considerations, now let's dive a little bit deeper into the indications for eCPR.
Speaker: Maybe, and you mentioned some of them, but could you just maybe describe the ideal patient for you first?
Speaker: Yeah.
Speaker: Sure.
Speaker: And I should, I guess, you know, surgery, I should, I should highlight that.
Speaker: Like think when you talk about the registry studies, you need to remember that these are generally patients that made it onto ECMO successfully, right?
Speaker: There are probably patients that they attempt to cannulate that never make the registry because they never actually were on ECMO and those clearly are negative outcomes, right?
Speaker: So be cautious when you look, because 30% sounds pretty good.
Speaker: And, and also same kind of the other caveat to think about, and I'll get to your question in a second is when you look at some of the RCTs, these are excellent centers, you know, the Prague group, these are, these are, these are groups that have the timing down, have the equipment ready, have the resources and are really good at what they do.
Speaker: And even those, um, and, and don't get me wrong, I'm an ECMO enthusiast, right?
Speaker: So I want to be doing ECMO whenever we possibly can.
Speaker: You just have to be really careful because even the best, um,
Speaker: the outcomes I wish were better.
Speaker: So if I think about, and I think it all comes down to patient selection.
Speaker: So if I think about the ideal patient, who is it?
Speaker: It's someone who is having this refractory cardiac arrest that CPR has failed, conventional CPR has failed, and it's going to continue to fail, but we're early enough in the course.
Speaker: And so you're able to decide once again, that this is someone who's not going to get ROSC and needs to be heavy CPR.
Speaker: Ideally, it's a shockable, initial shockable rhythm.
Speaker: Ideally, it's of some sort of reversible
Speaker: process.
Speaker: So that's generally going to be some sort of cardiac etiology, right?
Speaker: So someone with a STEMI who then has a V-fib arrest, that's a perfect candidate.
Speaker: Someone who has a large PE and obstructive shock and arrests, and you know that you can establish flow, take them to the lab, do a thrombectomy, that's a perfect candidate.
Speaker: A young person with myocarditis who you think you can support them and that viral myocarditis is going to improve and get better, that's a good candidate.
Speaker: But someone who has congenital heart disease or a bad malignancy that's leading to some sort of complication that leads to cardiac arrest, those are not good candidates.
Speaker: I think that's how I would think about it, is someone who's got a reversible process that you can get early on and that has good high-quality CPR up until cannulation.
Speaker: Excellent.
Speaker: And in terms of a of contraindications, could you maybe talk about absolute versus relative contraindications?
Speaker: You mentioned a lot of things that are very useful.
Speaker: We can we can repeat those.
Speaker: But just how how do you approach this when you get called down to make that decision?
Speaker: Yeah, you can quote me on this, or maybe I shouldn't be quoted, but I sometimes feel like evidence-based medicine is the gold standard, but that anecdotal medicine is better, right?
Speaker: And we've all had those personal experiences where we're like, I know the literature says this, but I'm going to do this instead.
Speaker: And I'm not advocating for that, but I think that using this term absolute is hard, right?
Speaker: Because there's always someone who maybe has an absolute, and you're like, actually, that was a good idea.
Speaker: And I can give you a story that I think is that after I kind of go through these that I think rings true for that.
Speaker: But some of the generally speaking Napsu Chondra indication would be a patient with either tamponade, so large pericardial effusion you're not going to want to put on that can make things much worse.
Speaker: Someone that has free fluid and you think has a perforated viscous or has a ruptured aneurysm, for example, AAA, you're not going to want to put them.
Speaker: on.
Speaker: So someone that's bleeding from hemorrhagic shock is not going to be a candidate.
Speaker: And then some of the relative things are those end stage diseases we talk about, heart, lung, kidney, liver, right?
Speaker: Metastatic malignancy is another one.
Speaker: Although, you know, there's always scenarios where when you think about VV ECMO, you say you shouldn't put someone on with cancer.
Speaker: Yet, I know we had a patient who was
Speaker: was incredibly hypoxic.
Speaker: We put him on and he got chemotherapy, his lungs got better and he got off ECMO and he went on living and was able to get the treatment, you know, and so there's always exceptions.
Speaker: Then title I mentioned, I think that's a big one.
Speaker: And then probably the biggest is if there isn't a cannulator, you don't have perfusionists.
Speaker: If someone, if they're far away, that's someone, you know, it is going to be more than 60 minutes before you get flow.
Speaker: That's someone you should walk away from.
Speaker: Don't do the procedure just because you can.
Speaker: Absolutely.
Speaker: And you mentioned, and I'm going to jump back to the indications.
Speaker: So you mentioned some clinical scenarios like VT, refractory VT with ischemia, somebody with an acute MI, acute pulmonary embolism, myocarditis.
Speaker: The other one that I have never seen or haven't used it for that, but I've seen a report in the literature, which obviously affects younger patients sometimes, is drug overdoses.
Speaker: Any comments on that, Adam?
Speaker: Yeah, that's tough.
Speaker: That's tough.
Speaker: I don't know if we have done that.
Speaker: But it's certainly possible, I think.
Speaker: You know, a component of this that I haven't mentioned that goes into the decision, whenever you cannulate anyone for ECMO, is what is the social support?
Speaker: Who's there to consent?
Speaker: This is not a minor procedure, right?
Speaker: So we really like to have someone we're speaking to.
Speaker: And especially because you can put them on, you're supporting their organs, they have severe neurological injury, then you're faced with a hard decision of how do you remove them from ECMO.
Speaker: And if you don't have someone to speak to,
Speaker: you get into a really dicey territory, right?
Speaker: So not saying that people with drug overdose don't have family.
Speaker: Of course they do.
Speaker: I'm just saying it increases the chance that, that, that, um,
Speaker: that you could get yourself into trouble.
Speaker: So I'm sure I could imagine a scenario of a cocaine overdose leading to V-fib leading to cannulation.
Speaker: We just haven't we haven't seen that.
Speaker: And maybe I should qualify that a little bit better.
Speaker: I think the case reports that I have read are really cardiac drugs.
Speaker: Like if you have a massive beta blocker overdose or calcium channel blocker, you can be in refractory shock, right?
Speaker: And have a cardiac arrest.
Speaker: And that's where maybe that has been reported.
Speaker: But I hear that's what you're saying, and that's why I wanted to ask.
Speaker: Yep.
Speaker: It's not coming out yet, but we wrote a little editorial.
Speaker: There's some really interesting stuff specifically about calcium channel blocker overdoses.
Speaker: And...
Speaker: And pretty good outcomes in cannulating.
Speaker: I mean, I and I can think of we've done three.
Speaker: And I remember one of them, profound shock, profound shock and was wide awake, not intubated.
Speaker: And I actually consented the family.
Speaker: But I remember speaking to her as I was doing the procedure.
Speaker: Right.
Speaker: Pretty, pretty dramatic.
Speaker: And another same thing.
Speaker: He was intubated, but he was totally awake, profound shock.
Speaker: And we and they did quite well.
Speaker: So for those scenarios, yeah, we've used it for sure.
Speaker: Perfect.
Speaker: And that's the same thing, right?
Speaker: The drug is going to go away and they're going to get reversible.
Speaker: So like that's the one you want to do it with.
Speaker: Excellent.
Speaker: And obviously getting a good history is going to be important because you don't have a lot of time, but like you mentioned,
Speaker: So, unwitnessed cardiac events, prolonged low flow or actual no flow times are all going to be the determinants that you probably would say, no, this is not a good candidate.
Speaker: So, that's very important.
Speaker: Once you have a patient who in the ICU and the OR or in the ED, I guess, let's talk about in hospital cardiac arrest to start.
Speaker: It has a cardiac arrest.
Speaker: You start ACLS.
Speaker: You start CPR.
Speaker: You're not getting to the point.
Speaker: You get called.
Speaker: You're thinking of ECMO.
Speaker: Can you tell us a little bit more about...
Speaker: how it really happens.
Speaker: So let's start with the cannulation and what's the appropriate timing.
Speaker: I'm sure it's as soon as possible, but how do you manage timing?
Speaker: Who cannulates?
Speaker: Where do you cannulate?
Speaker: And what's the preferred vascular access?
Speaker: That's a lot of questions.
Speaker: It is.
Speaker: All right.
Speaker: You got to keep me on track when I start to wander.
Speaker: So what happens at our institution, and we're a relatively young ECMO program, and we do, I would say, 40 to 50 cases a year.
Speaker: That's BV, VA, and ECPR.
Speaker: And it's taken us some time, but we have what's called a code ECMO program.
Speaker: So when there's a patient who, and this could be any ECMO, we think that needs to be cannulated, anyone can call the operator.
Speaker: And there's a handful of people that get alerted.
Speaker: So it is the intensivist that's on ECMO call.
Speaker: We have a tiered
Speaker: uh cannulation strategy where there's some providers who can do vb some that can do va and some that can do ecpr and that comes with experience and so you have to have if it were ecpr one of them immediately available which isn't always the case right so we can't do it all the time um
Speaker: Perfusion gets notified.
Speaker: And so they get notified.
Speaker: And then usually our advanced heart failure, there's some other consultants that don't necessarily come.
Speaker: And then our critical care nurses in our main ICU get notified and they show up with the tools and equipment.
Speaker: We bring a TEE to every cannulation.
Speaker: And we go anywhere in the hospital.
Speaker: So preferred would probably be the ICU, although we've been doing more and more cases in the ER.
Speaker: And I know you said in hospital, but sometimes patients sitting in the ER do it.
Speaker: And so I would consider that in hospital, right, even if they're physically in the emergency department.
Speaker: And so we call and we show up.
Speaker: I think it's really important that there is the CPR team.
Speaker: And then there's the ECMO team.
Speaker: And these are separate teams functioning differently.
Speaker: So the CPR team is doing all the stuff you need to do for ACLS.
Speaker: And that when you're the ECMO attending and deciding to can you later or not, you really shouldn't also be trying to run the code.
Speaker: You need definitely distinct teams.
Speaker: And you do as quick as you can look at the chart and understand.
Speaker: You find if there is someone, a surrogate.
Speaker: And honestly, sometimes there is not an immediate and you have to make a decision, but ideally you're able to speak to a surrogate.
Speaker: And then we get ready to cannulate.
Speaker: Does that do you need more details in terms of that?
Speaker: Or is that that kind of makes sense?
Speaker: No, I think that that tells, I mean, the response and who cannulates.
Speaker: And in terms of location, obviously, you kind of go where the patient is, right?
Speaker: But but when you look at the literature, people talk about ED versus OR versus cath lab versus ICU.
Speaker: But you don't move the patient from the ICU or from the ED to the OR, the cath lab to cannulate.
Speaker: Correct.
Speaker: Correct.
Speaker: We don't move them.
Speaker: We don't move them and we do it wherever we can.
Speaker: You know, I think the Inception trial, which is the most recent trial looking at ECPR outcomes, the time from hospital arrival, now this was out of hospital to cannulation, was somewhere in the realm of 15 minutes, right?
Speaker: So, fluoro is really helpful to see where your wires are.
Speaker: TEE is great to see if there's an identifiable cause of the arrest.
Speaker: and can also help to make sure that the wire's in the appropriate place.
Speaker: But yeah, no, we don't move the patient where they are is where we do it.
Speaker: And then how does it... Go ahead.
Speaker: You lose the floral support, but obviously you gain on the time, which is super important.
Speaker: Yeah, yeah.
Speaker: You know, if...
Speaker: But that's kind of, honestly, that happens for any of the ECMO cannulations, even VV.
Speaker: If they're sick enough that they need it, they're not stable to move from one place to an ICU.
Speaker: So we tend to cannulate wherever they are and then go from there.
Speaker: Sometimes the pace of VA is a little different, and you can move a kind of semi-urgent patient to a better location that needs VA.
Speaker: Yes.
Speaker: And obviously, the OR and the cath lab might also be places where people are rest.
Speaker: So that might be the site where you do the cannulation for that reason.
Speaker: Yep.
Speaker: We've done a couple massive PEs, you know, orthopedic procedures and big emboli, and then developing massive PE that we've cannulated in the operating room.
Speaker: Okay.
Speaker: Now, we talked a little bit about who cannulates the location, the timing, and you mentioned inception.
Speaker: So as soon as possible, is there a cutoff where you might just say, okay, we've been trying to cannulate.
Speaker: I mean, we're done.
Speaker: We can't get it.
Speaker: I think it all just depends on each patient, right?
Speaker: If you're seeing signs of life, if you have high quality CPR, your end title is acceptable.
Speaker: If I think age plays a big role, right?
Speaker: Honestly.
Speaker: And I think there's no dead set cutoff.
Speaker: I do believe that low flow time should be under 40 minutes, ideally.
Speaker: And I think that's a
Speaker: is the amount of time it takes to establish flow.
Speaker: Excellent.
Speaker: And in terms of the preferred vascular access sites, what do you usually do?
Speaker: It's going to be VA, obviously, because you're doing both circulatory and oxygenation support.
Speaker: But what do you do?
Speaker: Yeah, so it's going to be fem-fem always for VA.
Speaker: It's always going to be fem-fem in this scenario.
Speaker: And I will say, ideally, when we cannulate for VA, the drainage, which is the vein,
Speaker: is we always say and you'll you'll read in some literature talks like inflow and outflow which gets confusing to me so we just refer to drainage and return always respective to the patient of course so the drainage in the vein is a multi-strate multi-stage cannula and then the arterial return um and so
Speaker: What we prefer to do for VA is have them on different sides.
Speaker: And that a lot of that has to do with venous congestion, you know, blocking the vessels.
Speaker: And it's been shown if you have them on different sides, so one on left, one on right.
Speaker: There is less of chance of limb ischemia.
Speaker: But when you're doing ECPR, I'll be honest, you know, I'm sure we've most people here have done have done a femoral a line or any a line and you get that stick and you see the wire and you put the cannula in and you get this beautiful blood pulsatile.
Speaker: bright red blood pulsating, right?
Speaker: And you're like, yes, I'm in the artery, right?
Speaker: Or maybe you're trying to do a triple lumen in the IJ and you accidentally hit the carotid.
Speaker: You're like, oh no, I'm in the artery.
Speaker: But we've all kind of know what that looks like.
Speaker: You don't really get that with eCPR, right?
Speaker: Because the heart's not working, they're dead.
Speaker: And so sometimes with CPR, you'll see pulsation, but you don't always know.
Speaker: And so what we do is I like to do the same side, because then when I have two wires in, assuming I go at
Speaker: vein and the lateral ones probably in the artery.
Speaker: So I know if you do opposite sides, you're always worried that you're in vein and vein or even artery and artery, right?
Speaker: Makes sense.
Speaker: So you usually get what you can, right?
Speaker: But usually your practice is to go on the same side, and it's always going to be femoral for these patients.
Speaker: Perfect.
Speaker: So I stick one.
Speaker: I stick one.
Speaker: I look at where the wire – I get a wire in.
Speaker: I look to see where the wire is, and then I see if there's a vessel lateral or medial to it, and that tells me if I think I'm in the vein or the artery.
Speaker: Generally, I like to stick the artery first if I can, but really whatever is – you do what you can.
Speaker: And then we go from there.
Speaker: There's a lot of talk, and maybe this is, maybe I should wait to do this, but a lot of talk about reperfusion cannula.
Speaker: And if you should do it or not do it, we never put a reperfusion cannula in during an eCPR case.
Speaker: That always will come later after they're cannulated.
Speaker: And that's a little different operation when you're doing kind of a semi-urgent or elective VA case.
Speaker: For sure.
Speaker: So basically, you get the cannulas in, you set the patient up on the circuit, and what happens then?
Speaker: I mean, even though there's not immediate ROC, it doesn't matter anymore, right?
Speaker: Right.
Speaker: So a lot of times you put them on.
Speaker: And they are non-pulsatile.
Speaker: So they're non-pulsatile.
Speaker: That means you're not, you know, you'll get a MAP, but it's just flat.
Speaker: You're not going to get a systolic and diastolic.
Speaker: Or if you do, there's like not a huge difference between it.
Speaker: It's sometimes unlikely you're even going to have pulse ox because without the pulsation, it's hard for it to read.
Speaker: And so you still titrate your vasopressors.
Speaker: You kind of get flow going.
Speaker: And if they're flowing at three, four liters, you're happy.
Speaker: You titrate your sweep kind of basically.
Speaker: on how acidotic you think they are obviously use your vent the best you can and then you start to look to see if there's reversible reasons for why it happened and what's what's neat and what kind of probably the beauty of eCPR is is not only does it restore perfusion to all of your organs so that it decreases the chance of you know gut ischemia or noctic injury or liver you know shock liver but it also increases your coronary perfusion pressure so all of a sudden you're more likely to
Speaker: So a lot of these patients once you get flow will then start contracting and get ROSC and How do you manage kind of the next 24 48 hours?
Speaker: Is there anything that you do that's unique to eCPR?
Speaker: So number one figure out what caused it and see if you can reverse that right so
Speaker: So go to the cath lab if you need to, kind of determine that.
Speaker: I think that's number one.
Speaker: Number two, we like to get, we like to do CTs on all of these patients and understand if there's other injury or other things happening.
Speaker: You know,
Speaker: A lot of patients have neurological injuries, so understanding that's important.
Speaker: And then we kind of looked out for the big complications and the big concerns.
Speaker: And I think the three main concerns or immediate complications are limb ischemia.
Speaker: So we really pay attention to the perfusion of that leg with the cannulas in it.
Speaker: And we can talk about kind of what we do and how we do and what we do about it.
Speaker: Number two, we really think about the left ventricle and if it needs to be unloaded.
Speaker: I think for the most part, if the LV is down, we unload almost all of them.
Speaker: And there's debate whether that should be a balloon pump or an impella.
Speaker: I think for us, it's usually an impella.
Speaker: And then third, we always worry about north-south or Harlequin syndrome and making sure we address that to avoid cerebral hypoxemia.
Speaker: Could you expand a little bit on the north-south syndrome just for those who are not as familiar with ECMO?
Speaker: Yeah, yeah.
Speaker: So I'll try to kind of explain it the way my simple mind thinks about it.
Speaker: But the way I think about it is you have an arterial cannula sitting in the femoral artery.
Speaker: It's going counter flow, right?
Speaker: And it's pumping it three or four liters up the femoral artery and the aorta, right?
Speaker: And then you have...
Speaker: your native heart.
Speaker: And so when it's non pulsatile, there's no competing flow out of the heart.
Speaker: It's and so that good oxygenated blood is bypassing the heart and going up to the brain, making sure your brain is oxygenated, making sure your upper extremities are oxygenated, right?
Speaker: That's why we all and the way we make sure is we always do a right radial a line because it's the farthest from that.
Speaker: So if there's good PO2 there, then there's probably good PO2 in the brain and everywhere else.
Speaker: But as that heart starts to function again and starts to beat, it contracts, and now all of a sudden there's forward flow that's competing in what's called a mixing cloud.
Speaker: And so if that mixing cloud moves further down the aorta as the heart is gaining strength—
Speaker: all of a sudden that nice easy pathway of oxygen oxygen blood up to the brain doesn't happen and so if your lungs are okay not a big deal right because that blood that's coming out of the heart is well oxygenated from the lungs and it'll go north and it'll take care of everything and we have this we have these tissue perfusion monitors that kind of tell you what your what your oxygenation is and tissue oxygenation is and that's how we tell if there's a problem as well as the right radial a line right so
Speaker: It's not a problem, but where it becomes a problem is if you develop kind of LV ballooning out and pulmonary edema.
Speaker: And keep in mind, these patients almost, they take some sort of renal injury, right?
Speaker: They get some ATN.
Speaker: They're getting tons of press or tons of volume.
Speaker: So it's really common to get pulmonary edema.
Speaker: And now if bad blood, bad deoxygenated, not well-oxygenated blood's coming out of the heart and going north, then you develop something called north-south or Harlequin syndrome.
Speaker: So you need the heart to be pulsating for that to happen, obviously, which is maybe an advantage short term of a non-pulsatile patient on ECPR.
Speaker: But it seems that there are certain things that are potential or that you need to manage differently where the patient has ROSC or not.
Speaker: And that's one of them.
Speaker: Are there other things that you do while they have no pulsations versus when they have pulsations that might be of importance?
Speaker: Yeah, I mean, I think the biggest concern is that LV ballooning out, right?
Speaker: So if they're not pulsating and there's no forward flow, then they'll get thrombus in the left ventricle.
Speaker: And if that starts to happen, it's a death sentence.
Speaker: You're in big trouble, right?
Speaker: And so that's what we talk about LV unloading, which is essentially a balloon pump or an impella that's pulling blood to make sure that that LV stays decompressed as much as you can.
Speaker: So I think that's a huge focus.
Speaker: Yeah.
Speaker: That's probably the biggest difference for pulsating versus non-pulsating.
Speaker: And that's an important distinction because sometimes for people who are not as familiar with ECMO, you might think, well, why are you adding a balloon pump?
Speaker: Why are you adding an impellant?
Speaker: You're already on ECMO, right?
Speaker: And it is, they do different things and it's because you're trying to unload the LV.
Speaker: What are other complications?
Speaker: You mentioned, obviously, complications that you need to manage.
Speaker: Anything with infection or neurological complications that you manage with these eCPRs in particular?
Speaker: Yeah, I'm trying to think.
Speaker: So, infection is just your normal situation.
Speaker: how you would normally handle infection.
Speaker: Obviously, you have large-bore cannulas that are at increased risk.
Speaker: A lot of these patients are, all these patients have a temperature water bath, then you have, so a lot of them don't have fevers, right?
Speaker: Because the blood flow is leaving the body at whatever, five liters a minute, and then going through a water bath that's making it 98.6 degrees and then going back to the patient.
Speaker: Kind of like if you think about your CRT patient, a lot of them becomes hypothermic because it's leaving the body.
Speaker: If you don't have that water bath, then they will
Speaker: become, they'll become hypothermic.
Speaker: So they don't necessarily mount a fever.
Speaker: So we're much more sensitive to bandemia.
Speaker: And I think our trigger to give antibiotics is, is, is pretty low.
Speaker: We, we, we do it pretty quickly.
Speaker: So we that neurological,
Speaker: The incidence of neurological injury in these patients is really high.
Speaker: We think a lot about the rate of PCO2 change, and this is probably more for VV, but certainly for VA too, and that we don't want there to be a huge abrupt drop in their PCO2 when you put them on.
Speaker: So we're a little cautious about how we use the sweep and obviously get them out of life-threatening acidosis, but we're a little cautious about it because a rapid drop in PCO2 has been associated with poor neurological injury.
Speaker: outcomes in terms of brain bleeds and swelling, etc.
Speaker: So we're really aware of that.
Speaker: And I think the last one is a limb ischemia that I talked about.
Speaker: And so we will put reperfusion cannulas in if we think that there's a chance that there's limb ischemia not getting good distal blood flow where the cannula is.
Speaker: Let's talk a little bit about how we wean eCPR.
Speaker: And I guess there's two big potential trajectories here.
Speaker: We find a reversible cause, things are getting better, and we move forward versus, and we'll talk about that first, versus
Speaker: We don't find a cause.
Speaker: We're not getting pulsations.
Speaker: Or there's some other disaster that really indicates that this is not going as we had hoped.
Speaker: So when patients are progressing well, how do you think about weaning the eCPR support?
Speaker: Yeah, so that's a great question.
Speaker: And essentially what happens is you'll see good contractility, your vasopressors will wean off, and you will just be on flow.
Speaker: And we do what's called a ramp trial where we will, under echo guidance, usually TEE, but not always, and we will slowly decrease our ECMO flow.
Speaker: to the point where we have to keep some flow we don't want the circuit to clot off but that they become more and more dependent on their native cardiac function and if their basal pressors don't change and their map stays good and we look at the squeeze you know they're not developing right heart failure as we're decreasing and you know and unloading because if you think about it when you're flowing you're draining
Speaker: from the IBC.
Speaker: So that's the perfect way to offload the RV.
Speaker: And as I'm flowing less and less, the RV has to be able to handle it.
Speaker: And so if I can see that they're handling it well, then that would be the trigger to say, okay, I think it's time to decannulate.
Speaker: It's really not much more scientific than that.
Speaker: No, and I think it's important, obviously, just to appreciate how it happens.
Speaker: Now, what about
Speaker: Patients who are not doing well.
Speaker: So is there like a no ROSC time that tells you this is really not going to work or it depends also on what you found?
Speaker: If you have no clue why they coded and they're not having ROSC is very different than you think you know what happened, but you still don't have ROSC versus you have ROSC, but there's other complications.
Speaker: Can you talk about what's projected when patients don't do very well?
Speaker: You know pretty quickly.
Speaker: The tempo of VA and ECPR is much different than the tempo of VV.
Speaker: And you know really quickly.
Speaker: I'm thinking about a young woman that we took care of who had toxic shock syndrome and had developed severe cardiomyopathy, and we put her on...
Speaker: on va and despite that and doing all the appropriate things her lactate kept going up she had shock liver she was in dense atn she was really acidotic right you you know pretty quickly that it's not going to work um and i think this is probably one of the main reasons too that it's just so important to have family and consenting consentable um someone to consent because
Speaker: Part of our consent is to say, hey, if things are not going well, we don't want to hurt this person more.
Speaker: We'll let you know, and we will let you know that it's time to stop, and you kind of have to buy into it.
Speaker: Obviously, it's a joint decision, but we found that it's really important to be up front and say we may come to you and say that this has failed, in which case we need to stop together.
Speaker: When you have patients who neurologically are not recovering, so let's say you fix the heart or you have ROSC, do you think of neuroprognostication any differently than you would in another cardiac arrest patient?
Speaker: Yeah, not really.
Speaker: I mean, it's important if you're going to be an ECMO center, it's important to have your own ECMO-specific process.
Speaker: um, ECMO specific brain death criteria.
Speaker: Uh, but you can do apnea tests now in VV, you can turn off the sweep, right?
Speaker: And that's okay.
Speaker: But if they're on VA, you have to keep the sweep gas on.
Speaker: Um, the sweep is what kind of facilitates CO2 removal.
Speaker: And if your sweep is off, you would essentially be putting the oxygenated blood, um,
Speaker: into the arterial system.
Speaker: So you have to keep the sweep on.
Speaker: But no, you can do acne testing.
Speaker: We tend to do imaging usually.
Speaker: But the process to declare someone brain dead is very similar.
Speaker: And in terms of those patients who have severe anoxic injury but are not brain dead, follow the same algorithm you use for other post-cardiac arrest survivors?
Speaker: Yeah.
Speaker: Yep.
Speaker: Yep.
Speaker: Same thing.
Speaker: So we do TTM.
Speaker: We do TTM through the circuit.
Speaker: We will get imaging the same way we normally do.
Speaker: We talk to the family the same way we normally do.
Speaker: You know, we obviously in those scenarios, we kind of if it's capable to get them off MCS, we get them off MCS to simplify things.
Speaker: But no, all the same way.
Speaker: Yeah.
Speaker: And in general, because you mentioned that you, you know, pretty quickly, have you found or the registries suggest or show that ECPR runs are just shorter on average than VV runs for sure.
Speaker: And then other VA runs.
Speaker: Oh, I don't know.
Speaker: I think for sure.
Speaker: I mean, it,
Speaker: I think it's shorter than VV without a doubt, right?
Speaker: We've all seen those studies on 100 plus day VV runs.
Speaker: And VA in general is much shorter.
Speaker: But yeah, I would assume that eCPR, that's probably just because the mortality is high.
Speaker: So you have a mortality time bias.
Speaker: And so in general, the median time is going to be shorter.
Speaker: As we try to put things together at the bedside, what are some common pitfalls that you would recommend clinicians avoid as they are thinking of ECPR or learning about ECPR or starting an ECPR program at their institution?
Speaker: Yeah.
Speaker: I...
Speaker: I knew you were going to ask me that.
Speaker: And I was trying to think of the best way.
Speaker: And I, you know, I, I love where I work and I love Cooper and, and I'm sure, I'm sure you have fond memories there and it's, it's amazing.
Speaker: And I should, and I love that we as the intensivist group are the ones who are at the bedside doing this.
Speaker: But I think it's really important to highlight just how important the rest of your consultants are.
Speaker: There's no way we could do this without really supportive vascular surgeons that help us with the decannulation of the arterial cannula, that help us with the...
Speaker: The limb complications, which happen, I think I cited, you know, a third of the patients in ECPR have some sort of ischemia or limb complication to the point where vascular surgery is consulted on every VA patient right after cannulation, regardless.
Speaker: So important to have your CT surgeons and obviously your interventional cardiologist to help with the cath or the, um,
Speaker: Or the impella or the balloon pump based on what you decide to do.
Speaker: And not to mention the advanced heart failure.
Speaker: So really just because the cannulation part itself is is one of the easier parts of managing these patients.
Speaker: and it's just respecting and having all the team there to do it.
Speaker: So that would be one.
Speaker: And number two, I think the pitfall is it's so easy to, the hardest decision is to not cannulate.
Speaker: And I'm telling you, like, I have so many memories where I'm at the bedside and they seem young and it's a V-fib arrest and, you know, but we are missing some information and the ECMO circuits there and you're ready to go.
Speaker: And then it's just so important to take a moment really
Speaker: dive deep and try to figure out if it's a good idea or not.
Speaker: Um, because I've been in those scenarios where I've cannulated and then found out more and they've had bad neurological outcomes.
Speaker: And I was like, shoot, you know, the, the discomfort and the, the, it's just so much more painful for the family.
Speaker: So really take time to make the decision correctly.
Speaker: That would be probably number two.
Speaker: And, you know, I should say, like, be cautious before jumping into eCPR.
Speaker: It's very clear that the more experienced you are, the better the outcomes are more than any other type of ECMO.
Speaker: It's so it's directly correlated.
Speaker: So if you don't have the volume or the expertise, then then I would be cautious to jump into it.
Speaker: And with that said, like.
Speaker: I know I'm giving you a lot, but you should really know, like spend time with the circuit.
Speaker: Things happen, and so the more you can spend at the circuit, understanding how to put it together, understanding how to set up the room for the cannulation, understanding if there's a problem, what to do, the better.
Speaker: It's just really all about touches.
Speaker: And clearly, obviously, this is a super high pressure, high stakes, but also time sensitive intervention.
Speaker: So making sure that you orchestrate the team in an appropriate way as you build, because nobody has a high volume ECPR program on day one, right?
Speaker: You have to start somewhere.
Speaker: And as we mentioned, I do believe that
Speaker: MCS in all its forms is increasing throughout the country and it's more likely to be at your program if you don't have it now and in your future.
Speaker: So it's very important.
Speaker: Any pearls of wisdom?
Speaker: I mean, you've shared some of them, but more things that you really think that you should start there.
Speaker: Oh, wow.
Speaker: I think I just, in my last vomit of words, I think I gave you all of the pearls of wisdom.
Speaker: Yeah.
Speaker: You know, just, as I said, read about it, think about it, question it.
Speaker: I would say, I think that's the biggest thing we've learned as we've kind of grown our program and started to publish on the topic and really think about it, is that it's such a new field.
Speaker: It really is.
Speaker: There are some dogmas out there that...
Speaker: that you should question, you know, like COVID brought us VV and we published on how medical intensivists could do VV successfully.
Speaker: And that was pretty novel.
Speaker: And now it's becoming more and more common.
Speaker: So I would everything you read, just take with a grain of salt and really think about it.
Speaker: Because the field is definitely is young.
Speaker: Absolutely.
Speaker: Anything in research that's exciting you up on the horizon, specifically with eCPR?
Speaker: Yeah, I don't know.
Speaker: I think it's all about patient selection.
Speaker: I mean, even these studies, the ones I cited, the biggest end was 300, right?
Speaker: So like with everything cardiac arrest, I think that the out-of-hospital versus the in-hospital are two very distinct populations.
Speaker: And even if you look at research on in-hospital cardiac arrest in general, it's lacking, right?
Speaker: It's definitely not as robust as out-of-hospital cardiac arrest.
Speaker: So understanding that, and I think the difference between V-fib and PES
Speaker: They're just, we lump them as one group of patients, and I think they're not.
Speaker: And so really, it's probably just patient selection and understanding who would benefit from what treatment modality, right?
Speaker: Absolutely.
Speaker: And patient selection is important for every therapy, but especially you have two factors that...
Speaker: are particular about eCPR.
Speaker: Number one is these patients to begin with have a very bad outcome, all comers.
Speaker: And number two, it's a super high resource intervention, right?
Speaker: Very invasive, very high resource.
Speaker: So trying to find the right patient that can, you can make a difference is important, but
Speaker: based on what you share with us, Adam, it is clear in your experience, but also in the literature that for some patients, for the right patient, this might be a game changer.
Speaker: This might be the difference, right?
Speaker: And that's where, who you want to try to identify.
Speaker: Yeah.
Speaker: Yeah, definitely.
Speaker: Definitely.
Speaker: And, um,
Speaker: I wanted to share a story with you.
Speaker: I was hoping I could find the right time.
Speaker: Maybe now I can share a case that I think is kind of powerful and demonstrates it.
Speaker: This one sticks with me for a long time.
Speaker: I've kind of alluded to it throughout this hour.
Speaker: You know, I was this was kind of before we really did eCPR.
Speaker: We were diving into the VA world and I was called to the trauma bay.
Speaker: And it was a young woman who had a motor vehicle accident and had what we thought was just pulmonary contusions.
Speaker: And I was called to cannulate for BP.
Speaker: And by the time I arrived, which was pretty quick, she had had a cardiac arrest.
Speaker: She went to CAT scan and came back and h ad a cardiac arrest.
Speaker: And so we decided to cannulate her for VA.
Speaker: And unfortunately, she had suffered a devastating neurological injury too.
Speaker: And so she progressed to brain dead pretty quickly.
Speaker: And kind of what stuck with me is, number one, most trauma patients are going to be
Speaker: excluded because they're either bleeding or have neurological injury.
Speaker: So you got to be careful there.
Speaker: But what was kind of amazing about the case, and I think highlights just you never really know how things are going to go, is that she ended up progressing to brain death.
Speaker: And her, I think it was her nephew or no, maybe her cousin was was waiting for a liver and a kidney.
Speaker: donation.
Speaker: He's been listed at a local transplant center and she was a match and so she ended up being progressing to brain death, being declared brain death and then going and being procured and he got both of her organs.
Speaker: And so
Speaker: I guess I think that just highlights sometimes you don't know where things are going or what's going to happen and just do the best you can for every patient, right?
Speaker: Yeah, I know it's a powerful story.
Speaker: And a reminder for intensivists that even in the patients who we have who are declared brain death or who are going to be made a comfort care because they had some devastating injury, there is still the possibility of using their organs and their donors to
Speaker: to save another life, right?
Speaker: And even though that patient's usually not under our care, we have a responsibility to those patients as well.
Speaker: So it is a very powerful, powerful story and a great reminder for all of us.
Speaker: Adam, we'd like to close the clinical discussion with a couple of questions that are unrelated to our clinical topic.
Speaker: Would that be okay?
Speaker: Yeah, of course.
Speaker: Of course.
Speaker: So the first question relates to books and what book has influenced you the most or what book have you gifted often to other people?
Speaker: Oh, wow.
Speaker: So I was prepared for this after listening to your podcast.
Speaker: And so I think I could go a bunch of different directions.
Speaker: Admittedly, I used to read a lot more and I know you're a prolific reader.
Speaker: And so I aspire to be like you.
Speaker: But the one that came to mind was...
Speaker: if you've read it um and it it will make you never want to prescribe an antibiotic again um so i can give you a little bit about it or i can just leave it at that whatever you prefer but perfect predators is an excellent read for those of us in the medical field i highly recommend it so i actually do believe i read it and uh because um it relates to a synodobacter correct
Speaker: Yes.
Speaker: Yes.
Speaker: And one of my dear friends, younger friends, was actually on the research team that started using, was it prions or?
Speaker: Bacteriophages, yeah.
Speaker: Bacteriophages.
Speaker: Yeah, and they gifted that book.
Speaker: So I will definitely, we'll leave it there, but I agree.
Speaker: It's a great read.
Speaker: So I will definitely leave it there and put it in the show link.
Speaker: So perfect predator.
Speaker: Awesome.
Speaker: Yeah.
Speaker: Yeah, you'll be convinced.
Speaker: I will say after you read it, you'll be convinced we're all going to die from gram-negative bacteria.
Speaker: And you'll finally wash your hands, right?
Speaker: That's right.
Speaker: Awesome.
Speaker: So is there something you could share with us that you have changed your mind about in the last couple of years?
Speaker: Yeah, so this one's easy.
Speaker: This one I knew you were going to come with, and the answer is succinylcholine.
Speaker: That's what I changed my mind about.
Speaker: And I know you probably wanted me to stay away from medical, but I grew up, always grew up in fellowship.
Speaker: That's a funny thing to say.
Speaker: In fellowship, I always used ROC.
Speaker: We would never, ever, ever use tuxilcholine.
Speaker: And honestly, I was just, and the reason was I was so, I remembered that
Speaker: Being a intern and arriving at a code of a young man with pancreatitis that got succinylcholine to get intubated and he was in renal failure and had hyperkalemia and died during that intubation and I attributed it to succinylcholine I said I would never ever use it.
Speaker: And then Brian Fuller came and gave a ground round at our institution at Cooper, and he talked about the awareness trial.
Speaker: And it it really struck me the number of patients that probably get registered.
Speaker: rock to be intubated and are still paralyzed and awake underneath.
Speaker: And it convinced me that I should always use succulent choline if I can.
Speaker: That PTSD for the survivors is bad enough that we should be very aware of that.
Speaker: Fascinating.
Speaker: And that is perfect.
Speaker: It's something you change your mind about.
Speaker: So that is an interesting one.
Speaker: So definitely, I don't think I really read the awareness trial.
Speaker: So I'm going to have to look into that.
Speaker: And the last question really is more of a closing statement.
Speaker: Is there anything you want our listeners to know?
Speaker: Could be related to medicine, could be outside of medicine?
Speaker: I don't know.
Speaker: There's so many things I could say.
Speaker: I think I'll make it a kind of
Speaker: apply to medicine still, I think it's easiest for me.
Speaker: And I was trying to think about like specifically being intensivists and what we offer.
Speaker: And I think my piece of advice and something that took me a while to realize is that by far our biggest attribute is being available.
Speaker: And that I found the physicians, the intensivists that I think do the best are not the ones that they're all brilliant and proceduralists and can do all the things, but the ones that realize that our true value is being available at the bedside whenever the patient needs us.
Speaker: being the communicator between consultants and kind of putting our ego away and realizing that, you know, we need to ask for help and get people on board and just get the team moving in the right direction.
Speaker: So that would be my advice, especially to young people who are going into the field.
Speaker: It's just like that's what we bring is always being available.
Speaker: And I think that's something to be proud of.
Speaker: That's a perfect place to stop.
Speaker: Adam, I want to thank you for sharing your expertise and your time with us.
Speaker: Definitely learned a lot about ECPR and that we'll have to look at that awareness trial, but also highly recommend our listeners to read Perfect Predator and hope to have you back on the podcast soon to talk about other fascinating topics related to the practice of critical care medicine.
Speaker: Thank you.
Speaker: Thank you, Sergio.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
